ECHELON 4

15A NCAC 18A .1608 (b) Wall and ceiling attachments, such as light fixtures, fans, and vent covers, shall be kept in good repair. Observed touch up paint needed to walling in residents rooms.

15A NCAC 18A .1610 (a) Residential care facilities shall provide toilet, handwashing, and bathing facilities that are available for use by residents and employees that are kept clean and in good repair. Observed bottom of shower curtain liner with brown build up. Clean/replace.

15A NCAC 18A .1615 (a) The external premises of a residential care facility shall be kept clean, and free of litter and pest harborage. Observed dilapidated furniture stored outside near dumpster. Remove.

15A NCAC 18A .1618 (a) All food service equipment and utensils shall be kept clean. Observed minor debris build up to shelving in refrigerator and pull out drawer in freezer. Clean.

15A NCAC 18A .1608 (b) Wall and ceiling attachments, such as light fixtures, fans, and vent covers, shall be kept in good repair. Observed blue wall paint peeling in room 1 located on level 1.

15A NCAC 18A .1617 (a) Furnishings, including furniture, curtains, draperies, and blinds, shall be kept in good repair. Mattresses shall be kept in good repair. Observed mattresses topper peeling in room 1 located on level 2.

15A NCAC 18A .1621 (d) The residential care facility shall have personal protective equipment on-site for employees to use and a written procedure for employees to follow when responding to vomitus or fecal matter on facility surfaces. The procedure shall specify the actions that should be taken to minimize the exposure to vomitus or fecal matter. Facility did not have copy of required procedure plan. EHS emailed facility copy of required procedure plan. -General comment.

Observed carpet in need of cleaning in bedrooms 1 and 2. **15A NCAC 18A .1607 All floors shall be kept clean and in good repair.

Observed bathroom floor upstairs in need of repair. Observed carpet frayed at the top of the stairs. **15A NCAC 18A .1607 All floors shall be kept clean and in good repair.

Observed wall in need of repair in bedroom 3. Observed ceiling and wall in need of repair in the bathroom downstairs. **15A NCAC 18A .1608 (b) Wall and ceiling attachments, such as light fixtures, fans, and vent covers, shall be kept clean and in good repair.

Observed vent cover missing in bedroom 1. **15A NCAC 18A .1608 (a) The interior walls and ceilings, including doors, window, and window trim, shall be kept clean and in good repair.

Observed dresser under the bed in need of repair. Observed cabinet knob missing in both bathrooms. Observed curtain torn in bedroom 1. **15A NCAC 18A .1617 (a) Furnishings, including furniture, curtains, draperies, and blinds, shall be kept clean and in good repair. Mattresses shall be kept clean, dry, and in good repair.

Observed knob missing on dresser and mattress cover staining in bedroom 1. **All furniture, mattresses, curtains, draperies, and other furnishings shall be kept clean and in good repair. 15A NCAC 18A .1617 (a).

Observed wall damage in bedroom 1 and bedroom 3. Observed wall railing missing and door frame in need of repair in bedroom 2. Observed ceiling peeling in the bathroom upstairs. **The walls and ceilings of all rooms and areas shall be kept clean and in good repair. 15A NCAC 18A .1608.

Each resident will be provided soap and individual towels. These towels will be stored separately after being used. 15A NCAC 18A .1610 (b). Observed no paper towels at handsink located in restroom on second floor. Toilet, handwashing, bathing, and laundry facilities shall be kept clean and in good repair. 15A NCAC 18A .1610 (a). Observed debris build up in tub located on first floor.

All floors shall be easily cleanable and shall be kept clean and in good repair. 15A NCAC 18A .1607. Observed carpet staining throughout facility.

The walls and ceilings of all rooms and areas shall be kept clean and in good repair. 15A NCAC 18A .1608. Observed hole in wall near bed in room 2. Observed hole on outside of closet door in room 2. Observed touch up paint needed to walls and baseboards throughout facility.

Observed dresser handles missing in bedrooms during the inspection. Observed dresser drawers off track in bedrromm 3. **All furniture, mattresses, curtains, draperies, and other furnishings shall be kept clean and in good repair. 15A NCAC 18A .1617 (a).

Observed carpet with staining. Observed linoleum torn in the laundry room and downstairs bathroom. **All floors shall be easily cleanable and shall be kept clean and in good repair. 15A NCAC 18A .1607.

Observed touch up paint needed. Observed black staining on the walls in the bathroom upstairs. **The walls and ceilings of all rooms and areas shall be kept clean and in good repair. 15A NCAC 18A .1608.

Observed vent cover on the wall near the stairs in need of cleaning. **Ventilation equipment shall be kept clean and in good repair. 15A NCAC 18A .1609 (b).

Observed clothes stored on the floor in bedroom 1. Waiting for basket for resident. **Rooms or spaces which are provided and used for the storage of clothing, personal effects, luggage, necessary equipment and supplies and for items not in routine use, shall be kept clean. 15A NCAC 18A .1616 (a).

Observed carpet staining in bedrooms 1 and 2. Observed linoleum torn in the bathroom downstairs. **All floors shall be easily cleanable and shall be kept clean and in good repair. 15A NCAC 18A .1607.

Observed ceiling peeling in upstairs bathroom and the kitchen. Observed bacteria growth on the wall in the upstairs bathroom. No exhaust fan present. Observed wall in need of cleaning in the upstairs bathroom. **The walls and ceilings of all rooms and areas shall be kept clean and in good repair. 15A NCAC 18A .1608.

Observed torn shower liner in the upstairs bathroom. Needs to be repaired. **Toilet, handwashing, bathing, and laundry facilities shall be kept clean and in good repair. 15A NCAC 18A .1610 (a).

Observed dresser drawer damaged in room #3. Needs to be repaired. **All furniture, mattresses, curtains, draperies, and other furnishings shall be kept clean and in good repair. 15A NCAC 18A .1617 (a). Observed torn blanket in room #2. Needs to be repaired/replaced. **Clean bed linen in good repair shall be provided for each resident and shall be changed when soiled. 15A NCAC 18A .1617 (b).

Observed clothes stored on the floor in rooms #1 and #2. Ensure clothes are not stored directly on the floor. **Rooms or spaces which are provided and used for the storage of clothing, personal effects, luggage, necessary equipment and supplies and for items not in routine use, shall be kept clean. 15A NCAC 18A .1616 (a).

Observed carpet fraying in rooms #1 and #2. Needs to be repaired. **All floors shall be easily cleanable and shall be kept clean and in good repair. 15A NCAC 18A .1607.

Observed touch up paint needed throughout facility. **The walls and ceilings of all rooms and areas shall be kept clean and in good repair. 15A NCAC 18A .1608.

-Observed the white utensil container in the kitchen drawer collecting debris. Clean. All containers and clean utensils shall be stored in a clean place. 15A NCAC 18A .1618 (f). -Observed bowls and plates that are stored in the cabinet as clean with a lot of buildup on them. Remove all and clean. All multi-use eating and drinking utensils shall be thoroughly cleaned after each usage, and the facilities needed for the operations of washing and rinsing shall be provided. 15A NCAC 18A .1618 (b).

Observed no paper towels at the restrooms nor kitchen handwashing sinks. Provide. Hands must be washed properly before entering the refrigerator. Each resident will be provided soap and individual towels. These towels will be stored separately after being used. 15A NCAC 18A .1610 (b).

Observed badly damaged mattress covers, mattresses, and box springs in several rooms. Downstairs bedroom: rips on the mattress top and the side of the mattress is totally open to where the cushion and springs are exposed-Replace. Bedroom #2: torn mattress cover also with stains- Replace. Double bedroom: box spring badly torn & hole in the mattress cover on the left bed- Replace. All furniture, mattresses, curtains, draperies, and other furnishings shall be kept clean and in good repair. 15A NCAC 18A .1617 (a).

Observed clothes piled on the floor in the double room (right side) as well as hanging out of the basket and on the closet floor. Rooms or spaces which are provided and used for the storage of clothing, personal effects, luggage, necessary equipment and supplies and for items not in routine use, shall be kept clean. 15A NCAC 18A .1616 (a).

Repeat: Observed damaged flooring throughout the home- carpets fraying, laminate flooring lifting and or torn. Replace. All floors shall be easily cleanable and shall be kept clean and in good repair. 15A NCAC 18A .1607.

Observed a hole in the wall in the downstairs bedroom. The walls and ceilings of all rooms and areas shall be kept clean and in good repair. 15A NCAC 18A .1608.

Observed live roach in the kitchen. Provide pest control. Effective measures shall be taken to keep insects, rodents, and other vermin out of the residential care facility and to prevent their breeding, harborage, or presence on the premises. 15A NCAC 18A .1615 (a). Report emailed to awright@echeloncare.com

Observed the wooden toilet seat with damaged surface and exposed wood, the shower curtain liner was torn in the 2nd floor bathroom. **Toilet, hand washing, bathing, and laundry facilities shall be kept clean and in good repair. 15A NCAC 18A .1610 (a).

Observed some comforters with tears and exposed cushioning, pillows that were worn flat, furniture drawers were track, and the shelf behind 1st floor toilet was rusty. **All furniture, mattresses, curtains, draperies, and other furnishings shall be kept clean and in good repair. 15A NCAC 18A .1617 (a). **Clean bed linen in good repair shall be provided for each resident and shall be changed when soiled. 15A NCAC 18A .1617 (b).

Observed clean paper towels were stored beneath the sink drain in the 2nd floor bathroom. Do not store clean supplied beneath sewer drains. **Rooms or spaces which are provided and used for the storage of clothing, personal effects, luggage, necessary equipment and supplies and for items not in routine use, shall be kept clean. 15A NCAC 18A .1616 (a).

(REPEAT) Observed the flooring was damaged throughout the home. Large/wide runs in the carpet in the living room, bedrooms, hall and stair case; damaged vinyl flooring in the laundry area, both restrooms and the kitchen. Observed flooring in the kitchen is cut short and does not meet walls and cabinets in the kitchen; flooring at toilet in the 1st floor restroom also cut short - dirt and debris at curling edges of the vinyl. Eliminate all gaps in flooring to facilitate cleaning. Observed carpet tack strip was exposed at 2nd floor backdoor - tack strip was removed during the inspection. **All floors shall be easily cleanable and shall be kept clean and in good repair. 15A NCAC 18A .1607.

Observed wall paneling was damaged in one of the 2nd floor bedrooms, hole in hallway closet door and some bedroom walls, broken. missing section of chair rail in 2nd floor bedroom. Observed the ceiling with flaking paint above the shower in the 2nd floor bathroom. Observed bedroom door broken and off the hinges on the 1st floor. Observed chipping paint on the exterior porch columns. **The walls and ceilings of all rooms and areas shall be kept clean and in good repair. 15A NCAC 18A .1608.

Observed air temperature was 83-84F on the second floor, and the condensation pooling on the ground near the AC unit. Observed floor HVAC vents were rusty throughout the home, and a window pane made of Plexiglas was cracked / broken **Ventilation equipment shall be kept clean and in good repair. 15A NCAC 18A .1609 (b).

Observed the rear and side decks with worn and damaged wood; hand rails splintering and raised nails; Some sections of wood in need of replacing (steps/railing).. Observed several mosquito larvae in a small trash can near the AC unit. Ensure all containers are kept covered or inverted to prevent collecting water and breeding mosquitos. Observed the roof line with sections of missing metal flashing and exposed wood. **Remove wooden boards with protruding nails. **The premises shall be kept neat, clean, adequately drained, and free of litter and vermin harborage. 15A NCAC 18A .1615(a).

Observed stains presnet on linen in upstairs left bedroom. Observed knobs off drawer in downstairs bedroom Observed slight hole in door of upstairs closet. **All furniture, mattresses, curtains, draperies, and other furnishings shall be kept clean and in good repair. 15A NCAC 18A .1617 (a).

Repeat Non Compliance: Observed runs in carpet on stairs and in multiple rooms throughout house. Repeat Non Compliance: Observed stains on carpet in multiple areas Observed vinly floors bubbling around baseboard in kitchen. Observed debris build up present in downstairs bedroom. **All floors shall be easily cleanable and shall be kept clean and in good repair. 15A NCAC 18A .1607.

Observed upstairs light fixture leaning in right bedroom **Ventilation equipment shall be kept clean and in good repair. 15A NCAC 18A .1609 (b).

Observed damaged fence along left side of yard. **The premises shall be kept neat, clean, adequately drained, and free of litter and vermin harborage. 15A NCAC 18A .1615(a).

Repeat Non Compliance: Observed stove hood with accumulated grease and with rust, refrigerator gasket collecting debris and split. Repeat Non Compliance: Observed rust collecting in microwave, damaged peeling shelving paper, and debris collecting in bottom side of fridge. **Non-food-contact surfaces of equipment shall be cleaned at such intervals as to keep them in a clean and sanitary condition. 15A NCAC 18A .1618 (c ).

Repeat Non Compliance: Observed washing machine collecting residue around the lid hinges.Observed paper towels not present in upstairs restroom.**All residential care facilities shall be provided with approved sanitary toilet, hand washing and bathing facilities complying with state licensure requirements. 15A NCAC 18A .1610 (a).**\Toilet, hand washing, bathing, and laundry facilities shall be kept clean and in good repair. 15A NCAC 18A .1610 (a).

Repeat Non Compliance: Observed some bedroom dressers with surface damage, linen with stains present in upstairs bedroom and rip in pillow in bed room upstairs as well and worn mattresses. **All furniture, mattresses, curtains, draperies, and other furnishings shall be kept clean and in good repair. 15A NCAC 18A .1617 (a).**Clean bed linen in good repair shall be provided for each resident and shall be changed when soiled. 15A NCAC 18A .1617 (b).

Repeat Non Compliance: Observed carpet stained and or damaged throughout house, with vinyl peeling in upstairs and downstairs restroom with chips in kitchen floor at transitional from living room into kitchen. **All floors shall be easily cleanable and shall be kept clean and in good repair. 15A NCAC 18A .1607

Repeat Non Compliance: Observed ceiling surface damaged in upstairs restroom, downstairs in kitchen, wall paneling in upstairs restroom was damaged and not secured**The walls and ceilings of all rooms and areas shall be kept clean and in good repair. 15A NCAC 18A .1608.

Repeat Non Compliance: Observed ceiling and floor vents collecting rust throughout the house. **Ventilation equipment shall be kept clean and in good repair. 15A NCAC 18A .1609 (b).

Observed the stove hood w/ accumulated grease and w/ rust, and the refrigerator gasket was split/torn.**Non-food-contact surfaces of equipment shall be cleaned at such intervals as to keep them in a clean and sanitary condition. 15A NCAC 18A .1618 (c ).

Observed no soap was supplied to the hand washing sink in the 2nd floor bathroom. **Keep hand washing areas suppied with soap and towels.Observed the shower curtain with mold and mildew and the left sink drain was not attached to the sink causing water damage under the sink.

Observed some bedroom dressers with missing knobs, with surface damage. **All furniture, mattresses, curtains, draperies, and other furnishings shall be kept clean and in good repair. 15A NCAC 18A .1617 (a).Observed the sheets on a bed in one bedroom (1st floor) were not clean, and several pillow cases in several rooms needed changing. **Bed linens must be changed when visibly soiled.

Observed the carpet was stained/damaged throughout the house, the subfloor was not covered with carpet in the 2nd floor bedroom near the back door,, the bedroom floor with lifting vinyl at the toilet (2nd floor), and the floor vinyl was curling in the 1st floor bathroom, and debris collecting behind furniture and corners. **All floors shall be easily cleanable and shall be kept clean and in good repair. 15A NCAC 18A .1607.

Observed the ceiling surface was damaged in the 2nd floor bathroom at shower, wall panels/trim in the double bedroom was damaged/not secure, the door and wall with holes in the 1st floor bedroom, and the walls in the kitchen were splattered.**The walls and ceilings of all rooms and areas shall be kept clean and in good repair. 15A NCAC 18A .1608.

Observed ceiling vents and floor vents throughout the home with rust, and the ceiling light was hanging by its wires in the 2nd floor bedroom.**Keep all lighting and ventilation fixtures clean and in good repair.